Why do lactulose and rifaximin specifically help to treat hepatic encephalopathy?

In this episode, we break down why lactulose and rifaximin work specifically for HE: lactulose acidifies the colon to “trap” ammonia as ammonium (NH4⁺) and rapidly clears nitrogen substrates via catharsis, while rifaximin reshapes the gut microbiome and dampens gut-derived inflammatory signaling - benefits that don’t always correlate with serum ammonia levels. We also cover why other antibiotics fell out of favor, where polyethylene glycol fits, and how to think mechanistically about the best risk–reward strategy for preventing and treating HE.

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